TUBERCULOSIS: AFRICA: Straight talk with MSF medical coordinator

JOHANNESBURG, 22 June 2010 (PLUSNEWS) - Dr Eric Goemaere is the medical coordinator of Médecins Sans Frontières (MSF) in South Africa. His career in HIV and AIDS has spanned decades, moving from an era in which antiretroviral (ARV) drugs were beyond the reach of most, to a time where millions are living with HIV and on treatment. IRIN/PlusNews sat down with Goemaere to ask him about the future of funding, drugs and the fight against HIV.
QUESTION: Has MSF experienced cuts in international funding and, if so, how is this affecting its programmes?
ANSWER: Indirectly. In some of our programmes in Uganda and in Kenya we have seen patients coming to us - and sometimes from far away - and saying, 'Where I used to get access to my drugs, I've been told, No'. By default, they come to an MSF programme where there are still treatment slots available. For the moment these numbers are limited, but in the future they might grow to the tens of thousands, and that would definitely put a strain on the programme. MSF is a very small fish in the pond ... we choose to be privately funded and we are extremely restricted in our funding. We are not in a position to absorb the withdrawal of funding, and we do not want in any way to pretend [to do] so. Q. Second- and third-line drugs are out of reach to many living with HIV and TB; as HIV/AIDS becomes increasingly less "exceptional", what is that likely to mean in the development of these drugs? A. MSF are supporting patent pools ... to avoid going back to those battles we had in the beginning of the 2000s against pharmaceutical companies. A patent pool is a sort of win-win agreement where [pharmaceutical companies] give up their patent to a pool; in exchange they get royalties for that, as part of a totally negotiated agreement. In the United States, someone diagnosed HIV-positive at 20 years old has a life expectancy of 69 years. Why so? There are an almost unlimited number of regimens, or different drugs that you can combine, to ensure that once resistance comes up you have an alternative. Here [in Africa], we don't have that luxury - we have two bullets; two regimens - so we estimate that we can offer [someone diagnosed with HIV] 10 years [or so] ... at this stage.
Q. How serious is the threat of drug resistance?
A. Drug resistance is a problem, [but] this is a natural phenomenon and we will have to deal with it, although I would say it has accelerated [because] people are not adherent. Twenty percent, or one-fifth, of our patients have drug resistance after one year, [which] compares very favourably with some European cohorts. So it's not more of a problem, but it is an alarming problem for the good reason that we need to shift to second-line regimens, [which] ... are about five times more expensive than first-line regimens - so [drug resistance] will increase cost.
Q. Why isn't tuberculosis (TB) declining in South Africa?
A. The answer is very simple: the TB epidemic is fuelled by the HIV epidemic. To tackle the TB epidemic, you need to tackle the HIV epidemic ... 70 percent of TB patients are HIV-positive, so they are co-infected. In Khayelitsha township [outside Cape Town], where I work, the TB incidence rate has reached astronomical levels, with more than 6,000 new notifications per year - that is more than the whole of the United Kingdom in one township - and this was fuelled only by the high HIV prevalence. The good news is that when you get a good coverage with the ARVs, you immediately see the TB notification rate going down, and that's what we've been seeing for the last two years.
Q. What is the single biggest obstacle to tackling HIV in southern Africa?
A. It's combined factors, and the importance of these factors changes with time. In the beginning the biggest obstacle was drug prices; we managed to tackle that problem. Then the problem became about healthcare facilities, because HIV was treated mostly at central level [large hospitals in urban centres, which] required lots of doctors, and not many doctors were available. Slowly, surely, by increasing coverage we managed to decentralise care to primary healthcare level [clinics]. Today, unfortunately, the biggest problem might become funding. If not enough funding is available we [will] go back in time ... back to centralised care, with patients [coming for treatment when they are] sicker, and [case management] becoming more complicated.